Changing Behavior Through an Integrated Service Approach

CHANGING BEHAVIOR THROUGH AN INTEGRATED SERVICES APPROACH

Jon S. Matthew

November, 2006

 

Introduction

The hard part about integrated services is integrating. Integrating means organizing and connecting together disparate or autonomous elements in a plan of action. In the world of human affairs, an element is a person or a unit of people. Integrating also means matching one’s action to the need being presented. Organizing, connecting, and matching are processes required for doing a job competently. The organizing part refers to developing and maintaining the capacity of a person or a unit for acting, for conducting operations to achieve objectives in a complex environment. The connecting part refers to the process of coordinating with other individuals or units, each probably having a different capacity for action, to achieve objectives jointly defined. Matching refers to bringing the right resources to bear at the right point in time to accomplish the objectives. These processes require a high degree of communication between units. The communication must be meaningful and on time to get the job done properly.

Integrating is required for solving any complex task. The integrated forces must be nimble, that is, light on their feet, to adapt quickly and effectively to changing events. The environment is changing all of the time, requiring new combinations of responses and application of resources. There are many aspects of this communication process, from gaining intelligence (assessment), planning (plan-of-care), and implementation (monitoring and coordination). Understanding the needs (or conditions) presented is required for defining the task ahead. Each action taken to address need changes the requirements of the task, as the "object" (the defined other) reacts to the first planned move of the "subject" (the intervenor).

In the children’s world, the behavior of the child is interdependent, meaning that the behavior is linked to and supported by the behavior of others, especially the behavior of the caretakers. In this scheme, children are not autonomous monads. To address their needs, the communications among caretakers (units) have to be essentially non-linear, a system of feedback loops, rather than consisting of concrete sequential steps. The thing being measured changes through the act of measuring. We have to factor in these subject/object difficulties when we assess behavior. Our capacity to address needs effectively requires that we accept this basic truth, that behavior is interdependent, when we consider the things we want to change.

This view of the world has sometimes been referred to as the ecological approach. Ecological principles that define the interactions of living organisms are at the heart of seeking behavior change in children we want to enroll in integrated services.

 

Integrated services is a state funded program in Wisconsin for serving children who have significant behavior problems. As a program, integrated services obtains its identity through its basic structure, through the model it provides for conducting operations, and through the process it offers for getting people to work together. The basic structures of integrated services are the partner agencies, a coordinating committee, a child and family team, a designated service coordinator, and a target family. The coordinating committee produces an interagency agreement for organizing, connecting, and matching responses of the agencies, also known as the players, to the needs of the population being served. A team is developed for each child and family enrolled. Integrated services identifies processes for team building, i.e., developing trust and cohesion on the team. The team includes the family, other informal supports, and the representatives from the agencies, such as providers. Integrated services also defines the tasks of the team, which are to assess, plan, and implement services, or service activities to address needs. The service coordinator helps facilitate the process so the team can organize, build cohesion, and, hopefully, match responses to the needs of the child and family. Integrated services defines the role of the service coordinator in performing these tasks, at least to some degree. The role of the service coordinator is highly complex and critical to effective team functioning. Service coordinators need high level skills to perform their functions properly.

Integrated services is different than other programs serving children with behavior problems. We might refer to these other programs as traditional approaches, whereas, integrated services cuts across the traditional categories. Integrated services is a framework for doing business. The power of integrated services is based on the fact that when done well it promotes conditions for integrating approaches across entities, persons, and disciplines that would otherwise likely operate independently of one another, given the way our bureaucratic systems are set up as a series of smokestacks and silos. Integrated services promotes coordination of effort, but the process of integrating must occur at several levels at once to be effective in promoting behavior change.

Four levels of integration occur in integrated services. First, a partnership amongst agencies, members of the community, and the families must be developed. This partnership is represented on the coordinating committee. Each member of this partnership agrees to provide time and resources to the team created for each child and family enrolled in integrated services. Secondly, the child and family team must be integrated. An effective team can get itself organized, can connect team members together, and can find ways to include people on the team who have needed skills, as well as people who have an important role in the child’s life. Thirdly, the goals in the plan of action should be integrated. This seems like a basic task, but it is not as easy as one might think. In fact, individuals on the team usually have different goals, or agendas, at least at first. For instance, one member of the team may want the child taken out of the home, while others may want the child to stay with her parents. Fourthly, the behavioral issues of the child have to be addressed. If this isn’t done effectively, that is, if integrated services can’t produce results at the bottom line considered favorable to the participants, then integrated services would not have a purpose for being. Integrated services must address needs at the level of behavioral process.

This training is about how to integrate activities at the level of behavior change. The discussion will focus on a variety of issues that affect behavioral outcomes. Team members should be aware of these factors to be in a better position to get to the bottom line, that is, to influence the child’s behavior in a favorable direction.

In traditional parlance, we are talking about addressing the mental health needs of the child. Ordinarily, we would employ a traditional clinical approach to address mental health needs. However, integrated services offers us an alternative from the traditional clinical approaches. In our discussion, we will use the integrated services approach to achieve our bottom line of better functioning on the part of the child. Traditional mental health services involve too many boxes and cul-de-sacs to be of much use with the children we have targeted in integrated services. In looking at integrated services as an alternative for serving children with severe behavior problems we will have to understand how to integrate activities at the level of behavioral process.

We will be talking about doing this in the natural setting, that is, in the child’s family, in the community where the family lives. Having the child grow and develop in their own homes, with their natural parents and siblings, will produce the best possible outcome for children in general. However, the family and community resources in the natural setting have to be up to the task. Integrated services is all about providing the supports and resources necessary to meet the child’s needs in the natural setting. Deviations from this course, involving out-of-home placement, or institutionalization, should be based on immediate necessity in the integrated services approach, with an eye toward finding ways of returning the child home and preventing future occurrences of placement out of the home.

The vast majority of children and families in integrated services will be served with this commitment to raising the child in the natural setting. A minority of children will need long-term placement somewhere. Those children may also benefit from involvement of a team approach at the local level, especially if the children are placed in local foster care, even if there is no prospect of returning the child home in the foreseeable future. Any form of institutionalization, such as long-term placements at Mendota or Winnebago Mental Health Institutes, or placements in residential treatment centers, are problematic from the standpoint of using an integrated services approach. These settings are not natural settings. Such placements create a sheltered, almost laboratory kind of environment for the child. As a result of these characteristics, these placements are not compatible with an ecological approach for raising children. Some of these kids, however, would also benefit from using a team approach, especially if the goal is to return the child to the community as soon as possible. Remember, however, that the act of institutionalizing a child may engender pathologies that will make it harder to integrate the child into the community. Although this result is unintended, it is consistent with the axiom stated above: the act of measuring the child’s behavior will change the child’s behavior. It is not hard to imagine why children identified as "mental patients" are not likely to achieve a balanced identity for themselves.

Long-term institutionalization of children in Mendota or Winnebago, or having a revolving door to local psychiatric units, is the bad news in the child caring system in several ways (should we count the ways). The good news is that integrated services hasn’t even come close to realizing its full potential for keeping kids in the community. Through using more skilled and sophisticated approaches at the local level the need for institutionalizing children in the future should decrease to a fraction of the children experiencing these placements today. These are the things that we care about -- we who are involved in providing integrated services in our communities.

Managing children in the community with difficult behavior is not an unreasonable expectation, provided that we at the local level are willing to learn how to be more competent in performing this task. In this scenario, the institutions would be utilized only for short-term stabilization, much like what occurs with the adult population in Wisconsin. Building capacity at the local level involves getting much better at addressing the bottom line, which is at the level of the behavioral needs of the children we serve.

As stated above integrated services has a structure, a mode of operation, and a set of processes identified broadly here as organizing, connecting, and matching. The mode of operation discussed above consists of using a team approach with a service coordinator. The service coordinator functions as a team representative (a voice for the team), a team motivator (an inspiration for the team), and as a role model for the team on how to use team process to accomplish the task at hand (a guide for the team). The service coordinator, in this model of operation, is an expert in team process, and as such assumes a leadership role on the team. The service coordinator is active in performing these functions during team meetings and between team meetings. Thus, the service coordinator meets with the players, or communicates with them, on a continuous basis. This active role is what is meant by the terms monitoring and coordinating. This position is not an administrative record keeping role, although that is part of the job. The service coordinator assumes an active role in defining the processes of organizing, connecting, and matching necessary for each individual child on the "caseload". In a well functioning, experienced team other members of the team also provide this kind of leadership. Good teams encourage this kind of participation on the part of all team members. It is actually a goal of team participation. However, most teams do not start at this level of integrated functioning. Teams, like anybody else, have to grow and develop. A well trained service coordinator is a key person in helping the team get better at doing its job.

We can ask the question: What is the job of the team? In my view, the purpose of the team is to really get down to the bottom-line; that is, to change the behavior of the child. We have to start with the problem. The problem anchors us. Knowledge of the problem is necessary to be able to define what we mean by success. Knowledge of the problem helps us to know when we are finished, when the team can disband because everything is going well. The starting point is understanding the problem. If we assess the problem correctly then we then we have a better chance of effectively addressing the problem.

People in integrated services remind us to avoid the pitfalls involved in using language such as "changing the behavior of the child", and "the problem is . . . ." They make a very good point, telling us to avoid language that implies blame or involves "finger pointing". People on the team can get on the defensive right away if they feel blamed. The language employed should promote trust, while at the same time guiding the effort to address the problem. Even the term "solving the problem" raises the hackles of some people, with good reason, as it implies that our job is to fix people who are defective. Integrated services encourages the use of the term "needs" in favor of the term "problems", when defining the task of the team. We certainly don’t want to splinter and fragment a team by using "loaded" terminology, which is so easily misunderstood. However, the reality is that the problem is at least implied in the need. We also have to keep in mind that we want the team to grow and develop. A trusting team does not get hung up on these semantic issues, but we can also say that a team does not become trusting if team members are afraid of the "elephant in the room", as expressed in their inability to even talk about the problems they are facing.

As you can see by this discussion, teams face many dilemmas in performing their work. Success in resolving dilemmas like these requires that we be sensitive to the potential for alienation. Alienation is the opposite of trust. Alienation is fear driven, while trust is hope driven. Resolving this complex dilemma, which is actually a dialectical dilemma, is probably the most basic reason for employing the integrated services approach.

Presenting a Visual Picture of Integrated Services

The foregoing framework of integrated services can be presented visually in the form of a four X three grid, with processes displayed on the ordinate and levels of integration displayed on the axis, as follows:

Processes for Integrating

 

Organizing Connecting Matching

 

Level 1:

Community

 

 

Level 2:

Team

 

 

Level 3:

Goals

 

 

Level 4:

Behavior

 

In each cell we can list the activities involved for each process at each level of integration. We can also identify the responses to the questions who, what, when, where, why for each activity listed in each cell. A related question is how each activity will work to accomplish the stated goals. Let’s talk about filling in this grid.

At any level of integration we apply the processes of organizing, connecting, and matching. We organize our existing resources and we create others. Organizing means that we define the task and then recruit, train, and guide staff to do the task. We build a cadre that is ready to do the job expected of them. We establish the ability of this "force" to be ready to respond when the need is presented, and we provide them the tools to act effectively. This group is prepared to respond to a variety of local conditions, and is built with enough redundancy to allow the group to function effectively while under duress, or when faced with adverse conditions. We organize at the level of the coordinating committee, and at the other levels, to develop a team, to set goals, and to address behavior.

We also have processes for connecting the units together. In integrated services, units could be agencies or team members. We connect these units together by defining a task or a job they have in common. Then we build communication channels between units. The process of connecting requires that the communications aptly describe the task or job ahead, foster meaningful interpretations, and create an impetus for defining joint action, with each unit’s role understood. The communications among units allows the units to coordinate efforts after the action has started, so the task can be followed through from start to finish. These communications are necessary for the purposes of connecting at all four levels.

Matching is the third type of process. Matching means fitting actions to need. Our actions are what we do to address the problem, which is the task we have defined. We have a force (or group, or person) ready to go, and now we use it. Matching is the process of how we employ this force. First we define the job ahead. Then we engage; we apply our resources. After the action has started, we make corrective moves, and so on, until the job is completed. This process unfolds in context, meaning in a specific environment, under specific conditions. How we engage depends on our ability to read what is going on in the field from moment to moment. Thus, we rely on immediate intelligence (meaningful information) from the field to know what to do next. We deliver the right resource, at the right point in time, to accomplish the task before us. Matching is a dance we do in response to changing conditions in the field.

Matching is not just a matter of expending the least amount of resources to get the job done; matching is about getting the job done competently. Performing a job ineptly is likely to make the situation worse than it was before we started. If we have wasted our resources we may exhaust ourselves, or we may miss the only opportunity to accomplish what we wanted to accomplish that we will ever have. In matching we use our resources correctly to achieve our aims. Matching is a more sophisticated process then what occurs with end stage thinking. End stage thinking is when we fix the end point as the objective without considering how you get from here to there. This is a common institutional mistake. Matching occurs in the moment, in response to changing conditions on the ground.

We can think of how matching occurs in the context of the coordinating committee, where the job is to develop the structures and resources for conducting integrating services. These structures and resources should be relevant for the population served. The coordinating committee might even be able to specify how to use these resources, but only in a general sense. Matching also occurs in the processes of organizing and connecting. On the coordinating committee we want to do those things that will help the coordinating committee pull together to get the job done. The same occurs within each child and family team that we develop. The task of the team is to organize itself, to pull itself together, so that it can be an effective instrument for addressing the needs of the child. This requires matching with team members, addressing their needs, to build a cohesive unit. An unorganized team, with poor communications, is not likely to accomplish much good. A team that is pulling together can turn its attention to matching with the child. The team is closer to the child than the coordinating committee. Thus, the team has the responsibility to match at the level of goal setting for the specific child, and to match at the level of behavioral interventions.

Integrating at the Level of Behavior

Consider for a moment, being in a classroom with a child who is acting-out. The classroom and the school building with all the people coming and going would be the field. The subject (intervenor) and the object (acting-out child) are part of that field. The teacher would have a crisis plan of some sort, that she would employ in making her response to the acting-out child. Her actions are dependent on what is happening in the field at the moment, and she gauges her responses to the immediate situation. She considers what she brings to the situation, how she can use herself and the field to her advantage, how to counter the risks, and what actions will restore balance. How she goes about this will depend on her preparation for such an event and her skills in responding to the dynamics unfolding then and there.

Good teachers are experts in group dynamics. Many teachers take great pride in this ability and see classroom management as an important part of their job. It doesn’t always work this way though, especially if the teacher gets fearful, out of balance, and loses control of herself and her classroom. Our hypothetical child, in those circumstances, is not likely to restore the balance on his own. We cannot expect a child to get a grip if the adults in the situation aren’t in control of themselves.

Matching in this situation means responding to the unfolding dynamics to restore balance. The expert teacher who is in control of herself uses her voice, her body, and the space to send the messages that will return the classroom to a balanced state. The teacher always has a back-up plan just in case the messages don’t "take", meaning the messages aren’t effective and the child doesn’t return to balance. The focus is always on sending the right corrective message to the child.

Every action taken is received by the child as a message. Messages received become points for reacting, either favorably or unfavorably. The child is always "reading" the dynamics going on in the situation. Remember that the child has been there hundreds of times before and draws on that concrete experience. The adult may have little or no experience with that child. When dealing with these situations, we need to tell ourselves that the child does not think like us; the child reacts to the moment. So we need to get into the moment with the child. We need to learn how to be in the here and now as that is where the child is.

Training in Behavioral Process

Below is a list of topics for learning how to address behavior at the process level. This list does not include everything we should know, but it helps us focus on the process of addressing behavior. Team members and service coordinators should certainly know much of the material in this list. The bad news is that learning all this would be overwhelming. The good news is that you do not have to go to graduate school to learn the practical applications of these things. We can know them intuitively, especially if the environment encourages this understanding. Thus, our objective here is not to send service coordinators back to school, or other team members. Our objective is to encourage this process of focusing on behavior in integrated services. Formal knowledge of these topics would be helpful in getting you there, but the application does not require the formal knowledge, just the conditions for using it.

In my view, all integrated services projects should attend to behavioral process. Unfortunately, this isn’t always the case for a variety of reasons. Often service coordinators and other team members start to act like administrators, who seldom focus on behavior process at the level of the child. They develop "resources" to do this work, and assume that the resource will do the job. The processes of organizing, connecting, and matching at the behavioral level with the child is "off the table" in the eyes of most high level administrators. They are detached from what happens in the "trenches", but the service coordinators, and other team members, shouldn’t be disconnected at this level. We do not want service coordinators, or other team members, to assume this position of ignoring behavior process.

Unfortunately, the system in place gives people an "out", meaning a way to avoid dealing with behavior process. This avoidance consists of assigning the task to an "expert", without any idea of what the expert will do at the level of behavior process. Will the expert’s responses be consistent with team goals? Will the expert’s responses be consistent with the child’s behavioral needs? If this resource is not part of the team process, how would that person be able to perform consistent with the team’s wishes? How would we know if the actions of the expert will help or hurt unless we get down to the understanding of how it will work? Will the designated expert communicate with us in a meaningful way, so we can find out the answers to these important questions? Often we don’t know until things have already "gone south", i.e., the child escalates and the provider rejects the child, kicking him out of the "program". When this occurs the child is hurt, and so is everybody else. We want integrated services to stop this spiral of failure (the revolving door of providers and placements).

How can integrated services projects encourage use of behavior process in making interventions? All integrated services projects can set the conditions for organizing, connecting, and matching at the level of behavior process. Let’s consider ways that this can be done.

(group discussion to follow).

Special Topics to Explore

The advantages and disadvantages of formal diagnosis

Vulnerability of the caretakers

The power of words

Power of the dialectic

Stages of team development

Strengths and weaknesses

Attribution theory

Signal detection theory

Reinforcement theory

The developmental perspective

The role of science and technology

Performing an assessment that focuses on behavioral process

Developing a plan using behavioral process

Monitoring and coordinating behavioral process

Cross-training of team members

Keeping the focus on the bottom line

The link with integrated medicine

Use of mobile crisis intervention

How to integrate traditional services into the plan

A typical child enrolled in integrated services

The importance of energy flow at the level of behavioral process

Gaining cooperation through motivational interviewing